CONGESTIVE HEART FAILURE ORDER SET. Check appropriate boxes: Admit to unit to Dr. l Inpatient l Observation l Telemetry.

Transcription

1 CONGESTIVE HEART FAILURE ER SET Check appropriate boxes: Admit to unit to Dr. l Inpatient l Observation l Telemetry Diagnosis: Consult Dr. Reason: l I have called Dr., add to his/her list. Diet: l NPO l Regular Code Status: l Full Code l Do Not Resuscitate l Palliative Care Consult l Do Not Resuscitate and Comfort Care Only NURSING ERS: Activity: l Up ad lib l Up with assistance l Bedrest l Up in chair with meals l Ambulate times daily Vital Signs: l Routine l every 4 hours l Daily Weights (no bed scale if able to stand) l Strict I&O l Notify for new onset of temp > Assess Smoking History and Counsel Pneumococcal Vaccine Screening and Influenza Vaccine Screening (Oct.-March) Oxygen assessment by pulse oximetry Respiratory Therapy: l O2 NBP L/min l Face mask oxygen at L/min or % Non-invasive positive pressure ventilation: l CPAP at mmhg l BiPap at mmhg Labs NOW (IF NOT DONE IN ED): l BMP l CMP l Lipid Profile l Magnesium l PT/PTT l CBC l CBC with Diff l TSH l BNP l Troponin I every 8 hours X Labs in AM: l BMP l CMP l Lipid Panel (fasting) l Magnesium l PT/PTT l CBC l CBC with diff l TSH l BNP Diagnostic Tests, unless done in the ED: l ECG l Portable Chest X-ray l PA and Lateral Chest X-Ray Other Physician Signature: Date/Time: Form # (01/11) Page 1 of 5

2 Consults: l Social Work Evaluation l Dietitian l Pharmacy for warfarin instruction Document EF: l Moderate/Severe ventricular dysfunction (EF< 40%) l Mild (EF>40%) l EF % per Echo dated l EF unknown Unit secretary to obtain copy of previous Echo l If no ejection fraction known, order echocardiogram to be done and read by l Cardiologist on call l Dr. Boland l Dr. Chang l Dr. Bart Williams l Schedule Outpatient echocardiogram (date) Physician to read: Reason for study: MEDICATIONS: DVT Prophylaxis (see attached order set) PRN Medications (see attached order set) l Diabetic Management Bundle (see attached order set) Therapeutic Anticoagulation (not DVT prophylaxis): l Enoxaparin 1mg/kg SQ every 12 hours: l Enoxaparin RENAL DOSING: CrCl < 30: 1mg /kg SQ q 24 hours l Warfarin mg by mouth po daily. Hold for INR > l INR daily l Heparin Infusion per protocol ACEI or ARB: Hold if l SBP less than 90mmHg l SBP less than 100 mmhg l Lisinopril mg po every hours l No ACEI or ARB because of (circle reason) Hyperkalemia / hypotension / renal artery stenosis Mod-severe Aortic Stenosis/ worsening renal function/ ACEI allergy/ ARB allergy Other Reason for not prescribing ACEI or ARB Diuretics: l Furosemide mg IV every hours l Furosemide mg PO every hours l Furosemide 100mg in 100 ml D5W at 10 ml/hour other rate ml/hr Beta Blocker: Hold if l HR < 50 bpm l HR < 60 bpm l SBP < 90mmHg l SBP < 100 mmhg l Metoprolol tartrate (Lopressor) l Metoprolol succinate (Toprol) l Carvedilol (Coreg) Vasodilators: l Nitroglycerin IV (50mg/250ml mcg/minute may titrate to mcg/minute l Nitroprusside IV (50 mg/250 ml D5W) Start at mcg/minute and may titrate to a max of mcg/minute Notify MD for SBP less than mmhg Titrate in increments of 0.5 mcg/kg/minute to keep SBP between mmhg (Note: Requires intra-arterial pressure monitoring and ICU admission) l Nesiritide IV per protocol Form # (01/11) Page 2 of 5

3 Inotropes: Requires ICU/PCU admission (Recommended only for patients with signs of cardiogenic shock: SBP less than 90mmHg, Cool extremities, prerenal azotemia with volume overload, mental status changes.) l Dobutamine (Dobutrex) IV mcg/kg/minute infusion. Start at mcg/kg/minute and may titrate to a max of mcg/minute l Milrinone (Primacor) IV 0.5 mcg/kg/minute infusion Other Medications: l Digoxin l Spironolactone Statin Therapy: l Rosuvastatin (Crestor) l Atorvastatin (Lipitor) l Simvastatin (Zocor) Other: Antiplatelet Therapy: l Aspirin 81 mg PO daily l Aspirin 325mg PO daily l Clopidogrel 75 mg PO daily Diagnoses present or not present on admission Secondary diagnosis/problems (this information can affect the patient s severity level) Indicate whether the condition was present on the patient s arrival at the hospital 1. Pressure Ulcer Yes No If yes, document site(s): 2. Foley catheter related UTI Yes No 3. Central Venous catheter associated infection Yes No 4. Poor glycemic control Yes No a. uncontrolled on admission b. admitted with DKA, coma or hyperosmolarity Yes No Other Orders: Physician Signature: Date/Time Form # (01/11) Page 3 of 5

4 PRN MEDICATION ERS: (Choose one for each condition) Nausea: l Promethazine (Phenergan) 12.5 mg IV every 6 hours as needed. l Promethazine (Phenergan) 25 mg IV every 6 hours as needed. l Ondansetron (Zofran) 4 mg IV every 4 hours as needed. l Ondansetron (Zofran) 8 mg IV every 8 hours as needed. Fever: l Acetaminophen (Tylenol) 650 mg po every 4 hours as needed for Temp. >101 l Acetaminophen (Tylenol) 650 mg suppository rectally every 4 hours as needed for Temp. >101 Cough: l Benzonatate (Tessalon Pearles) 100 mg PO q 6 hours as needed l Guaifenesin (Robitussin) 400mg PO q 6 hours as needed Indigestion: l Magnesium and aluminum hydroxides with simethicone (Mylanta) 30 ml po as needed. l Famotidine (Pepcid) 40 mg po every day as needed Constipation: l Bisacodyl (Dulcolax) suppository rectally as needed. l Magnesium Hydroxide Suspension (Milk of Magnesia) 30 ml po as needed. l Sodium phosphate enema (Fleets Enema) as needed. Anxiety: l Alprazolam (Xanax) 0.25 mg po every 6 hours as needed. l Diazepam (Valium) mg po every 6 hours as needed. l Lorazepam (Ativan) mg po every 6 hours as needed. Sleep: l Zolpidem (Ambien) 5 mg po every hs as needed and may repeat in 30 minutes. l Temazepam (Restoril) 15 mg po every hs as needed. l Temazepam (Restoril) 30 mg po every hs as needed. Pain: l Nitroglycerin 0.4 mg sl prn for chest pain, every 5 minutes x 3 l Acetaminophen (Tylenol) 650 mg po every 4 hours as needed. l Hydrocodone 5mg with acetaminophen 500 mg (Lortab 5 mg) po every 4 hours as needed. l Hydrocodone 7.5mg with acetaminophen 500 mg (Lortab 7.5 mg) po every 4 hours as needed. Respiratory: l Albuterol 0.083% (2.5 mg/3 ml) q hours routine and q hours as needed sob/wheezing l Ipratroprium 0.02% (0.5 mg/2.5 ml) q hours routine and q hours as needed sob/wheezing l Duoneb unit dose q hours routine and q hours as needed sob/wheezing l Other nebulizer: l Lipbalm (Blistex) to lips prn for dryness or irritation l Artificial Tears prn for dryness l Benzocaine/Phenol (Chloraseptic) Spray prn for sore throat l Vasolex cream to buttocks prn for dryness Physician Signature: Date/Time Form # (01/11) Page 4 of 5

5 Prevention of Hospital Acquired Venous Thromboembolism Venous Thromboembolism Risk Factors Age >50 year Prior history of VTE Acute or chronic lung disease Myeloprofilerative disorder Impaired mobility Obesity Dehydration Inflammatory bowel disease Known thrombophilic state CHF Active rheumatic disease Varicose veins/chronic stasis Active malignancy Sickle cell disease Recent post-partum w/immobility Hormonal replacement Estrogen based contraceptives Nephrotic syndrome Moderate to Major surgery Central venous catheter Myocardial infarction Venous Thromboembolism (VTE) Risk in the Hospitalized Inpatient LOW MODERATE HIGH l Ambulatory patient without l All other patients (most patients) l Elective major lower extremity arthroplasty additional VTE Risk Factors l Hip, pelvic, or severe lower extremity fractures l Ambulatory patient with expected l Acute spinal cord injury with paresis LOS <=2 days, or same day/minor surgery (not in LOW or HIGH category) l Major multiple trauma Only a few patients!! LMWH or UFH 5000 units q 8 hours l Abdominal or pelvic surgery for cancer Ambulation and Education LMWH or Arixtra or Coumadin, AND SCD Pharmacologic Prophylaxis Options: Choose ONE: l Enoxaparin 40 mg subcutaneous q 24 hours (both MODERATE and HIGH risk patients, except knee replacement) l Enoxaparin 30 mg subcutaneous q 12 hours (HIGH risk, knee replacement) l Enoxaparin RENAL DOSING: CrCl < 30: 30 mg subcutaneous q 24 hours (MODERATE and HIGH risk patients) l UFH 5000 units subcutaneous q 8 hours (MODERATE risk only) l UFH 5000 units subcutaneous q 12 hours (for MODERATE risk patients <50kg or > 75 years of age l Fondaparinux 2.5 mg subcutaneous q 24 hours (alternate in selected HIGH risk patients) l Coumadin mg po daily, target INR 2-3 (alternate in selected HIGH risk patients) l NO pharmacologic prophylaxis, patient has contraindication to pharmacologic prophylaxis or is on therapeutic anticoagulation (please check contraindications) l NO pharmacologic prophylaxis, patient has NO VTE risk factors listed and meets LOW risk criteria above. Mechanical Prophylaxis: l Venodynes (SCD) (Default adjunct in HIGH risk patients, or in contraindications to anticoagulation) l Graduate compression stockings l NO mechanical VTE prophylaxis Contraindications or other Conditions to Consider with Pharmacologic VTE Prophylaxis l ABSOLUTE l RELATIVE l OTHER l Active Hemorrhage l Intracranial hemorrhage within last year l Immune mediated HIT l Severe trauma to head or spinal cord l Craniotomy within 2 weeks l Epidural analgesia with spinal catheter with hemorrhage in the last 4 weeks l Intraocular surgery within 2 weeks (current or planned) l Other l GI, GU hemorrhage within the last month l Thrombocytopenia (<50K) or coagulopathy (PT > 18 seconds) l End stage liver disease l Active intracranial lesions/neoplasms l Hypertensive urgency/emergency l Postoperative bleeding concerns* *Scheduled return to OR within the next 24 hours *Spinal Cord or Ortho Spine: 7 days leeway *General Surgery, s/p Trauma admission: 48 hours leeway *Major Ortho: 24 hours leeway Physician Signature: Date/Time: PATIENT LABEL Form # (01/11) Page 5 of 5